Tests For Balance Without Gait Component Single-Leg Stance (Vellas, Wayne, Romero, Baumgartner, & Garry, 1997) 30-Second Chair Stand (Jones, Rikli, & Beam, 1999)
Scoring Considerations
Advantages
Disadvantages
ICF Domain
Timed task in static posture. Fall risk: normative data available for age and sex.
Quick and easy to perform; most normative data based on preferred stance leg.
Some inconsistency with preferred vs. dominant leg as stance leg; need to observe for compensatory movements. May be too challenging for frail older adult.
Body function.
Single timed activity. Fall risk: normative data available for age and sex.
Quick and easy to perform; should not use upper extremities to perform.
Body function and activity.
ICF = International Classification of Functioning. Normative values for various patient populations can be found at https://www.sralab.org/rehabilitation-measures, along with citations for statistical measures for a variety of patient populations. Original author cited in first column.
Note : From Western Schools, 2019. Strength and range of motion
Figure 2: Forward Head Posture Measurement
Basic areas of therapeutic evaluation should not be ignored, including extremity strength, ROM, and sensation, with emphasis on the lower extremities. Screening for strength loss that is related to fall risk can be accomplished easily through manual muscle testing, hand-held dynamometry, and functional lower extremity screens such as the 30-Second Chair Stand test or the 5 Times Sit to Stand test. Both tests can be used for a functional assessment of lower extremity strength in adults where standard lower extremity manual muscle testing and positioning may be contraindicated or difficult to accomplish. Lower extremity ROM is important to assess as limitations at any lower extremity joint can impact posture, balance, and gait quality. In particular, adequate ankle ROM is necessary for effective use of the ankle balance strategy, as well as adequate knee and hip ROM for effective hip and stepping balance strategies. Testing sensation on the soles of the feet using monofilaments is crucial for determining sensory deficits that could cause an older adult to rely heavily on vision or vestibular system function, both of which tend to decline in efficiency with age (Migliarese, 2017). Posture A general posture evaluation should be performed as part of the occupational or physical therapy evaluation, paying special attention to FHP and presence of kyphosis. An older adult who displays kyphosis and/or FHP may maintain static and dynamic stance toward the anterior limits of stability, creating an increased risk for falling forward even when perturbed by small forces from behind. A Reedco postural screening form is a commonly used assessment tool for posture (Booshanam, Cherian, Joseph, Mathew, & Thomas, 2011). Recent studies have linked FHP with increased risk for falls, possibly due to abnormal cervical proprioceptive feedback or abnormal vestibular feedback that must be integrated into effective balance and postural control strategies (Kang et al., 2012). Screening for geriatric posture can be accomplished using a Reedco Posture Scale (RPS), which includes visual observation of 10 postural traits that are assigned a value on a 0 to 10 ordinal scale (Gunther et al., 2005).However, this method has not proven to be as reliable for best practice. Cervical ROM can be reliably measured with instruments such as the Cervical Range-of-Motion device (Tousignant et al., 2006) and FHP can be measured in older adults by determining the craniovertebral angle via photographic imaging (Nemmers, 2009). The craniovertebral angle is an angle formed by a horizontal line drawn through the spinous process of the seventh cervical vertebra (C7) and a line joining the spinous process of C7 vertebra with the tragus of the ear (Yip et al., 2008; see Figure 2). The Kyphosis Index (Lundon, Li, & Biberstein, 1998) is an additional method of postural evaluation that involves placing a flexicurve ruler along the spine and then tracing the spinal curve on a grid paper.
Note . From Western Schools, 2019.
Functional mobility and ADLs Functional mobility and ADL performance is a standard component of any occupational or physical therapy evaluation and should definitely be included in a detailed fall risk assessment. Older adults with high fall risk may be avoiding certain movements or activities because of a previous fall, fear of falling, or poor self-efficacy with certain activities. For example, an adult at risk for falls may dress sitting down at the edge of a chair versus standing on one leg to pull on pants or put on sock and shoes. They may avoid standing in a wet shower to bathe and instead bathe at the sink while standing or seated. They may no longer engage in community outings that require more challenging mobility skills such as negotiating stairs without a rail, walking in dark environments or on uneven surfaces. Surveys such as the Activities-Specific Balance Confidence Scale (ABC; Nemmers & Miller, 2008) or the Modified Falls Efficacy Scale (Tinetti, Richman, & Powell, 1990), which will be discussed later in the course, can help identify avoidance behaviors and changes in ADL performance. Neurologic examination A general neurologic evaluation contains many components familiar to clinicians that will not be covered in detail here. This section will emphasize the basic neurologic components more likely to affect fall risk, although clinicians should keep in mind that areas such as reflexes, coordination, and cranial nerve testing may in indicated in older adults with chronic neurologic conditions or signs and symptoms of potential neurologic pathology. Sensory integration When performing a full neurologic examination there are important areas to emphasize that can contribute to fall risk in older adults. Recalling the earlier discussion of sensory integration and balance, inputs from three sensory systems should be examined for normal functioning, including vision, somatosensation, and vestibular afferent information. The modified Clinical Test of Sensory Interaction on Balance (mCTSIB; Figure 3) can identify use of these three systems to
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